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PARTICIPANT DATA CHANGE FORM Please complete the section(s) that apply to your request (Any incomplete forms will be returned) Section I: Personal Information Active Participant Retiree Terminated Participant Participant Name: Employer/Jurisdiction Name: Social Security Phone Number: E-Mail Address: Section II: Name Change (please submit a copy of the appropriate court documentation for your name change) □ Name Changed From: Section III: Address Change Password Letter Request (will be sent to email address listed above) New Old Section IV: Beneficiary Information 401(a) Defined Contribution Plan 457 Deferred Compensation Plan Defined Benefit Plan (If not checked, form applies to all Plans) If you are designating multiple beneficiaries, please be sure to mark “Primary” or “Contingent” for each You may use this form to designate the same beneficiary(ies) for all plans in which you participate. If you wish to designate different beneficiary(ies) for the DC and DB plans in which you participate, you must complete a separate form for each plan If you name more than one primary or contingent beneficiary, the to Beneficiary” for the category must equal 100% The to Beneficiary” can be split up to two decimal points (Example: 33.33%) The beneficiary(ies) designated on this form relates only to the receipt of Lump Sum or Balance of Period Certain Benefits payable under the Defined Benefit Pension Plan I hereby designate the following beneficiary(ies) to receive any death benefits payable under the referenced retirement plan(s), still reserving the privilege of future changes with the exception of the contingent/survivor benefit for the DB Plan. As a participant, I do hereby revoke any previous beneficiary information, and specify the below named persons as my beneficiary(ies). PRIMARY BENEFICIARY (If more space is needed, an additional sheet may be attached to this form) Male NAME OF PRIMARY BENEFICIARY Female SS# DATE OF BIRTH RELATIONSHIP ADDRESS % TO BENEFICIARY PLEASE CHECK PRIMARY OR CONTINGENT FOR THE ADDITIONAL BENEFICIARY(IES) PRIMARY CONTINGENT Male NAME OF BENEFICIARY Female SS# DATE OF BIRTH RELATIONSHIP ADDRESS % TO BENEFICIARY PRIMARY CONTINGENT Male NAME OF BENEFICIARY Female SS# DATE OF BIRTH RELATIONSHIP ADDRESS % TO BENEFICIARY If more than one primary beneficiary is designated, settlement will be made to each in equal shares unless otherwise specified above. If primary beneficiary(ies) does not survive me, settlement will be made to the contingent beneficiary(ies). If no designated beneficiary survives me, settlement will be made as designated by the Plan documents. Participant Signature: Date: Required Witness Print Name: Required Witness Signature: (MUST NOT BE LISTED AS A BENEFICIARY) For security purposes we prefer that these forms be submitted to our secure website by your current or former Employer. If you are unable to return the forms to either Employer, please follow the instructions below. Return To: ACCG Retirement Services, 191 Peachtree St. NE, Ste. 700, Atlanta, GA 30303/ or Fax to [PHONE REDACTED]/or email [EMAIL REDACTED] Phone [PHONE REDACTED] or [PHONE REDACTED]